Healthcare Provider Details

I. General information

NPI: 1124228655
Provider Name (Legal Business Name): SHAVONNE ANNETTE BRUBAKER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CRAPO ST SUITE 200
MT PLEASANT MI
48858-2941
US

IV. Provider business mailing address

655 E CEDAR AVE
GLADWIN MI
48624-2215
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-5938
  • Fax: 989-775-7701
Mailing address:
  • Phone: 989-426-9295
  • Fax: 989-426-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: